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ORAL CARE IS CRITICAL CAREThe Role of Oral Care in the Prevention of Hospi tal-Acquired Pneumonia

Independent Study Guide

Continuing Education Information

The Oral Care is Critical Care independent study guide has been accredited by Cross CountryUniversity, a Division of Cross Country TravCorps, Inc., a provider of continuing education in nursing bythe American Nurses Credentialing Centers Commission on Accreditation. 1.2 contact hours fornurses has been awarded for this independent study.Cross Country University is an approved provider with the Iowa Board of Nursing, Provider #328. Thisindependent study is offered for 1.2 contact hour.Cross Country University is an approved provider with the California Board of Registered Nursing,Provider #CEP 13345. This independent study is offered for 1.2 contact hour.Cross Country University is an approved provider with the Florida Board of Registered Nursing,Provider #50-3896. This independent study is offered for 1.2 contact hour.

To obtain contact hour credit the applicant must:

Read the educational material printed in this independent study guide Take the post-test located in the back of the booklet Complete all information requested on the evaluation form Submit the post-test and the evaluation form to:

Kimberly-Clark Health CareAttn: Esther Atkinson1400 Holcomb Bridge Road

Building 200, 5thfloor

Roswell GA 30076

Post-tests will be graded and, upon passing, a certificate will be issued and sent to the applicant. Lessthan passing (less than 75% correct answers) will have the post test returned and the applicantencouraged to re-read the material, take the test again and re-submit.

Disclaimer

Cross Country University has made reasonable efforts to ensure this educational subject matter ispresented in a scientific, balanced and unbiased way. However, participants must always use theirown judgment and professional opinion when considering future application of this information,particularly as this may relate to patient diagnostic or treatment decisions. Cross Country does not

endorse or promote any commercial product that may be discussed in this study guide.

Knowledge Network educational programs are designed to provide clinical education to healthcareprofessionals without reference to specific commercial products. This Knowledge Network independentstudy guide is provided at no cost through a continuing education grant from Kimberly-Clark HealthCare.

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ORAL CARE IS CRITICAL CAREThe Role of Oral Care in the Prevention of Hospi tal-Acquired Pneumonia


Suzanne Pear, R.N., Ph.D., C.I.C.

Kathleen Stoessel, R.N., B.S.N., M.S.Susan Shoemake, B.A.

Objectives

Understand the clinical classifications of pneumonia Discuss the risk factors of Hospital-Acquired Pneumonia (HAP) and Ventilator-

Associated Pneumonia (VAP)

Describe the path to Ventilator-Associated Pneumonia (VAP) Explain the role of the oral environment in the development of Hospital-Acquired

Pneumonia (HAP) and Ventilator-Associated Pneumonia (VAP) Examine recommended oral care interventions and the evidence-based rationales for

these patient care practices

Introduction

Hospital-acquired pneumonia (HAP) is the leading cause of healthcare-associated infections(HAIs) among mechanically ventilated patients in the intensive care unit (ICU). Pneumonia

accounts for nearly 15% of all nosocomial infections and 24% to 27% of all those acquired incoronary care units and medical ICUs respectively.1,2 Approximately one quarter of allintubated patients will acquire pneumonia - at a rate of 1 to 3% per day of intubation -prolonging their hospitalization, increasing their risk of death by up to ten-fold, and addingsignificant costs to their care.3,4,5,6,7,8,9 In fact, costs have been shown to increase as much as$40,000+ per incident.*10,11 In spite of extensive efforts to prevent and treat thiscomplication,12,13a mortality rate ranging from 25% to 70% is still associated with ventilator-associated pneumonia (VAP) and it is recognized that 60% of all HAI-related deaths areassociated with this infection.14 From a global perspective, pneumonia is the #1 infectiouscause of death in the world.15 (See Graph 1)

*(Please note, hospitals will have different cost values due to the virulence and antibiotic resistance

characteristics of the pathogen, the actual cost calculated (labor, drugs, length of stay, other costs associated withthe infection, extent of treatment of the related infections e.g. BSI. Thus there are numerous per incident valuesreported in the medical literature.)

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Graph 1. Global Burden of Infectious Diseases by DALYs

This disease has been called the forgotten killer of childrenand the old mans friendbecause it is a major cause of mortality in the very young and the elderly. 15

Several organizations and institutions,13such as the Centers for Disease Control andPrevention (CDC)16the American Association for Respiratory Care (AARC) and the AmericanThoracic Society(ATS)17,18have recommended strategies and approaches in an effort toaddress this prevalent infectious disease. Among the most commonly recommendedprevention strategies is one that is often overlooked at the patients bedside comprehensive

oral care. This study guide will review how hospitalized patients develop pneumonia and theevidence-based oral care strategies for reducing its occurrence. The normal host infectiondefense and secretion clearance mechanisms of the respiratory system will be compared tothat of the intubated patient. The alteration in the ecology of the critically ill patients mouth willbe discussed in relation to the role these changes play in the development of pneumonia. Interms of improved oral health and reduced incidence of HAP and VAP, the recommended oralcare interventions and clinical data to support these interventions will also be discussed. Atthe completion of this study guide, medical personnel should have a thorough understanding ofthe relationship between comprehensive oral care and the prevention of hospital-acquiredpneumonias. Comprehensive oral care is critical care.

Impact of HAP and VAP

The cost of HAP can be staggering in terms of incidence, lives and dollars.

HAP is the second most common cause of infection in healthcare. In fact, one out of everyfour ICU infections is pneumonia, with 90% of the incidence occurring in ventilated patients.

Approximately 9% to 27% of ventilated patients may develop VAP with these patients being 6

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to 20 times more likely to develop pneumonia compared to the non-ventilated ICU patient.Furthermore, there is an even higher VAP rate in Medical ICUs.19,20

When a non-ventilated patient develops HAP, it greatly increases the likelihood that the patientmay require ventilatory assistance. Additionally, VAP increases both the time a patient mustreceive mechanical support, as well as the amount of supplemental oxygen. Additionally,patients with VAP have longer lengths of stay in the ICU by approximately 6 days and excesstotal hospital lengths of stay (LOS) averaging 7-9 additional days as well.19,20

HAP and VAP also increase healthcare costs. In the United States alone, a hospital-acquiredpneumonia typically increases the cost of care by as much as $40,000 dollars per episode,19,20adding an estimated $1.2 billion dollars/year cost for the US Healthcare System.21

The mortality rate attributable to VAP may be as high as 70%.19,20 This is the highest for anyhealthcare-associated infection. Furthermore, even if patients do not die from the infection, thesubsequent lingering debility can be severe.

The Clinical Classif ications of Pneumonia

Pneumonia is defined as an acute inflammation of the lungs caused by an infection fromorganisms such as Streptococcus pneumoniae, other bacteria, viruses, rickettsiae, and fungi.Regardless of the setting in which pneumonia occurs, the presenting physical characteristicsare similar: productive cough with purulent secretions, chest x-ray which is positive for new orexpanded densities, fever and elevated white blood cell count. Figure 1 is a conceptualrepresentation of the clinical classifications of pneumonia.

Figure 1. Clinical Classifications of Pneumonia19,22

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The following definitions will provide a greater understanding of the different classifications ofpneumonia.

Community-Acquired Pneumonia23Pneumonia is classified as Community-Acquired Pneumonia23if the patient resides in thecommunity and has not been in a healthcare environment for at least 90 days or has notresided in a long-term-care facility for more than 14 days before the onset of symptoms. 24 Anestimated 3 million cases of CAP occur annually in the United States with one out of everythree patients requiring admittance to an acute care hospital for treatment of this life-threatening infection.19

Healthcare-Associated Pneumonia (HCAP)A recent addition to the pneumonia classification and one which can cause some confusion isHealthcare-Associated Pneumonia or HCAP. Healthcare-associated pneumonia (HCAP) isNOT considered the same as hospital-acquired pneumonia (HAP), although it is certainlyrelated. Healthcare-associated pneumonia refers to patients who develop pneumonia within90 days after discharge from an acute care hospital, nursing home or extended care facility, orwho receive dialysis services or home care and present with pneumonia on admission to an

acute care facility. This distinction is made to emphasize that these patients, whosepneumonia may occur in the outpatient setting, have risk factors for pneumonia (e.g., multiplecomorbidies, recent antibiotics, infections with resistant pathogens found in healthcaresettings) that more closely resemble HAP rather than CAP.19

Hospital-Acquired Pneumonia (HAP)Hospital-Acquired Pneumonia (HAP) is defined as pneumonia that develops at least 48 hoursafter admission and the infection was not present or incubating on admission. A quarter of amillion cases of HAP occur in the United States each year.19

Ventilator-Assciated Pneumonia (VAP)

A subset of HAP, Ventilator-Associated Pneumonia (VAP) refers to those cases that occur inpatients who have been on ventilatory support for at least 48 hours. The mechanisms for HAPand VAP infections are similar, although due to the fact that host defenses against pneumoniaare so effectively bypassed by an endotracheal tube, the risk of pneumonia in ventilatedpatients is much higher.19

Early-onset VAP is defined as hospital-acquired pneumonia that develops in patientswho have been on a ventilator between 48 and 96 hours or less than four days. Thesepatients may have had emergent, traumatic intubations or major chest, abdominal orneurosurgery. The usual pathogens associated with early onset VAP are mostcommonly the patients own normal, antibiotic-sensitive flora, such as methicillin-

sensitive Staphylococcus aureus (MSSA), Haemophilus influenzaor Streptococcuspneumoniae.14

Late-onset VAP is defined as hospital-acquired pneumonia that develops in patientswho have been on a ventilator five days or longer. These patients often present withmany pre-existing chronic conditions that predispose them to lung infections, such aschronic obstructive pulmonary disease (COPD) or cardiac-related pulmonary edema.The pathogens most commonly seen with late-onset VAP are the more resistant strainsof bacteria such as methicillin-resistant Staphylococcus aureus (MRSA) or gram-

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negative bacteria such as Pseudomonas aeruginosa,Acinetobacter, Enterobacter,Klebsiella or Serratia.14

Risk Factors for Pneumonia

Most, if not all, hospitalized patients are susceptible to pneumonia due to risk factors suchas:16

coma malnutrition supine position extremes of age insertion of nasogastric tube severe underlying conditions compromised immune system admission to the intensive care unit administration of antimicrobial agents immobilization due to trauma or illness

initial or repeat endotracheal intubation presence of underlying chronic lung disease conditions requiring prolonged use of mechanical ventilatory support surgical procedure involving the head, neck, thorax or upper abdomen

Ventilated patients are especially susceptible to pneumonia as their normal host defenses arehampered, blocked or disabled during mechanical ventilation by the physical presence of theassisted-breathing device. The bacteria and other microorganisms, which are normallyblocked or carried away from the respiratory tract, have the ability to bypass the normal bodydefenses and enter the lungs.

In order to understand the vulnerabilities of the ventilated patient, a review of the normalreflexes and clearance mechanisms is helpful.

Normal Reflexes and Clearance Mechanisms

Normal reflexes and secretion clearance mechanisms are required to reduce the negativeeffects of substances such as:

Air- Hot- Dry- Cold

Allergens and pollen Dust and other particulates

Atmospheric pollutants Irritating chemicals Microorganisms

- Bacteria

- Yeast- Fungi

Viruses

Host defences and clearance mechanisms include air filtration in the nasal cavity andmucous transport.

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Air FiltrationAs air is breathed in, it enters through the nostril openings (nares). (See Figure 2)Gross particles are filtered out by nasal hairs as the air moves toward and through theconvoluted passageway of the turbinates. Mucus seeps onto the tissues lining thesenasal passages to attract particles and further filter the air. While the process

continues, the air is warmed and moistened. This warming is necessary to increase thecapacity of the air to absorb and deliver moisture to the mucosal lining.

Figure 2. View of Normal Nasal Air Movement

As the air moves down the throat towards the trachea, many of the remaining particlesare impinged onto the adenoid tissues, which contain white blood cells that function todestroy incoming pathogens.

Mucous TransportThe downward flow of mucus, facilitated by the wave-like movement of cilia, togetherwith constantly draining sinuses transport the entrapped particles and pathogens into

the esophagus where they are swallowed before they can enter the lungs.

While swallowing, the soft palate flaps up to prevent the mucus from going back into thenose while the epiglottis flaps down over the trachea to prevent entrance into thetrachea. Prior to tightening the epiglottic hatch, the cleaned, warmed, moistened air isdrawn into the trachea by the vacuum created by the expanding lungs.

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Alternatively, the mucus may be transported upward from the trachea and downward bycilia from the nose to the back of the throat to be swallowed or expelled by coughing.

This has been referred to as the mucociliary escalator. (See Figure 3)

Figure 3. Mucociliary Escalator

The surface area of the respiratory tract is about50 times that of our skin (roughly the area of atennis court) Thats a lot of area to keep cleanand defend!

The Path to VAP

When there is an endotracheal tube (ET tube) in place, all normal functions change.Foreign body reactions in the tracheal tissues may occur and extreme pressures fromthe cuff can injure the tracheal wall potentially causing long-term damage.8 The ET

tube may also provide an environment wherein a biofilm may form and proliferate.Furthermore, its presence impairs natural protection and clearance mechanisms inmany ways. (See Figure 4)

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Figure 4. Pathway to VAP

The ET tube bypasses the normal filtration and physical capture functionsbyprohibiting nasal warming and humidification. This lack of warming decreases theability of the air to carry moisture. The lack of humidity causes the mucus to becomedried, thickened, and difficult to transport, thus allowing clumps to develop. Thesenormally moist patches of oral and pulmonary tissues become more vulnerable to injuryand infection.8

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The mucociliary clearance mechanism is also compromisedby the presence of theET tube.20 In many ways, the ET tube acts as a direct conduit for pathogen access intothe lungs.20,25 It blocks and disrupts the normal clearance via the mucociliary escalatorabove the tube cuff by interferingwith swallowing and forcing the epiglottis into an open

position. Secretions accumulate above the cuff,

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drain to the back of the throat andcontaminate the subglottic pool25providing an environment where normal flora andpotentially pathogenic bacteria can rapidly multiply.25 Also, by keeping the tracheastrap door open8contaminated secretions can drain into the trachea through the glottisbetween the vocal cords instead of into the esophagus.25

The ET tube also affects the function of the mucociliary escalator below the cuffas themovement of mucus from the trachea and lungs past the cuff is prohibited. Therefore,the mucus accumulates in the trachea below the distal tip of the ET tube until it ismanually removed.8 If not suctioned away, this bacteria-laden mucus and any dislodgedbiofilm particles can clog the opening of the ET tube or fall into the lungs.8

Inhibiting the cough mechanismis another negative consequence of intubation. Thepatient is sedated thus muting physical responsiveness, the tube blocks the coughreflex20and positive pressure from the ventilation pushes against any efforts to cough.

As this cycle of contamination, aspiration and pathogen multiplication continues, thesepathogenic microorganisms overwhelm the bodys antibacterial defenses and thepatient develops pneumonia.

The Role of the Oral Environment in the Development of Pneumonia

After reviewing the path to VAP, one can see the potential impact of the oralenvironment on the development of pneumonia. Therefore, it is important to have athorough knowledge of the microbiological environment of the mouth and the changeswhich occur when a patient becomes critiically ill, is hospitalized and is placed on aventilator.

Microbial EnvironmentMost oral bacteria are considered to be part of the patients normal flora and mayconsist of up to 350 different species. These various organisms possess a tendency tocolonize different surfaces in the mouth. For example, Streptococcus mutans,Streptococcus sanguis,Actinomyces vicosusand Bacteroides gingivalismainly colonizethe teeth while Streptococcus salivariusmainly colonize the dorsal tongue. Finally,Streptococcus mitisis found on both buccal and tooth surfaces.26 These flora areusually considered low-level pathogens which may take years or decades to producedisease. (See Figure 5)

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Figure 5. Oral Niches of Microbial Contamination

The oral flora of critically ill patients differs from that of healthy individuals and containsorganisms that can rapidly cause pneumonia. Within 48 hours of admission, thecomposition of the oropharyngeal flora of critically ill patients undergoes a change fromthe usual predominance of gram-positive streptococci and dental pathogens topredominantly gram-negative organisms, constituting more virulent flora, includingpathogens that cause VAP.27 Also, increased levels of proteases in the oral secretionsof critically ill patients removes from their epithelial cell surfaces, a glycoproteinsubstance called fibronectin. Normally, fibronectin is present on cell surfaces and actsas a host defense mechanism, blocking pathogenic bacterial attachment to oral andtracheal mucus membranes. This depletion of fibronectin allows cell receptor sites toreplace normal flora with virulent pathogens such as Pseudomonas aeruginosaonbuccal and pharyngeal epithelial cells.26

If the intubated patient does not receive effective, comprehensive oral hygiene, dentalplaque and hardened bacterial deposits develop on the teeth within 72 hours. This isfollowed by emerging gingivitis, gum inflammation, infection and a subsequent shift fromprimarily Streptococcus and Actinomyces spp. to increasing numbers of aerobic gram-negative bacilli.28

Since adhesion to a surface in the mouth is important for the continued existence andproliferation of organisms, bacteria which attach to the tooth surface gradually coalesceto produce a biofilm and after further development, lead to the formation of dentalplaque.29 (See Figures 6 and 7)

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Figure 6. Biofilm with Glycocalyx Figure 7. Dental Plaque

(Micrograph courtesy of Janice Carr, CDC, Atlanta) (Photograph courtesy of CDC, Atlanta)

Saliva

Saliva is also critical for the oral environment. The continuous production of saliva isessential to keeping the mouth, and its components clean and moist. By definition,saliva is a mixed fluid secreted predominantly from the parotid, submandibular andsublingual glands. It has a number of important functions such as washing food debrisand unattached microorganisms from the mouth. It neutralizes acids produced bybacteria on tooth surfaces and because it contains calcium and phosphorus, workstogether with fluoride in the remineralization of tooth surfaces. In addition, salivacontains a number of immune substances such as immunoglobulin A, which obstructsmicrobial adherence in the oral cavity, and lactoferrin which inhibits bacterial infection inthe healthy individual.29

In the intensive care patient, a severe reduction of salivary flow and subsequentxerostomia 30and mucositis31may result in oropharyngeal colonization with respiratorypathogens and the progression to VAP. During the day, in the healthy individual,unstimulated salivary flow ranges from 0.25 to 0.35 mL/min while stimulated flow mayreach quantities of 4 to 6 mL/min. Severe xerostomia is defined as an unstimulatedsalivary flow of less than 0.1 mL/min.32 Conditions in the critically ill which impactsalivary flow include fever, diarrhea, burns, reduced fluid intake and a number ofmedications such as opiates, anticholinergics and diuretics.32

Studies by Dennesen et al. have documented a nearly absent salivary flow in intubated,sedated ICU patients (See Graph 2) which can be explained by several circumstances

such as the severity of the disease resulting in intubation and admission to the ICU, lackof normal oral intake, fluid balance disturbances, extended use of morphine requiredbecause of controlled mechanical ventilation or pain management. Apart from theinadequate flow, the saliva is not distributed throughout the oral cavity in a supine,sedated patient and severe xerostomia is therefore generally present in ICU patients.

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Graph 2. Salivary Flow and Days in ICU

As mucositis or oral inflammation increases in the intubated patients mouth, the level oforal bacteria increases as well. (See Graph 3) The greater the level of oral bacteria,

the more biofilm will attach to the patients teeth. Allowing build-up of biofilm (dentalplaque) increases the bacterial load in oropharyngeal secretions.

Graph 3. Mucositis Index and Days in ICU

All patients aspirate secretions, even non-ventilated patients. The greater the amountand microbial contamination of aspirated secretions, the more likely pneumonia willoccur.

Oral Care Interventions and the Evidence-Based Rationales

Several organizations and patient safety initiatives, including the Centers for DiseaseControl and Prevention (CDC),16the Association for Professionals in Infection Controland Epidemiology (APIC),33Institute for Healthcare Improvement (IHI),34,35and the

American Association of Critical Care Nurses (AACN)36have developed evidence-based patient-care treatment practices for reducing the occurrence of HAP and VAP.

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Comprehensive oral hygiene has consistently been recognized as critical to theprevention of pneumonia in the hospitalized patient. (See Table 1) The CDCGuidelines for Preventing Healthcare-Associated Pneumonia recommend makingpatient oral hygiene standard practice as a VAP prevention strategy. Routine oraldecontamination is an effective method for reducing VAP by decreasing the microbial

load in the oropharyngeal cavity. It has been found that the incorporation of routine oralhygiene into standard practice may reduce VAP by as much as 60%.31

Table 1. Recommended VAP Prevention Strategies by Organization

Component CDC APIC IHI AACN Head of bed elevation (Semi-recumbent patient

positioning 30-45)

Daily sedation vacation and daily assessment ofreadiness to extubate

Peptic ulcer disease (PUD) prophylaxis

Reliable, comprehensive oral hygiene program Cleaning of equipment

Avoid routinely replacing ventilator circuits Hand hygiene Subglottic secretion drainage continuous or

intermittent

Prevention of oropharyngeal colonization

Most important for all patients is that the health care institution have a written oral careprotocol and training plan in place with the goal of ensuring that all patients receive

comprehensive oral care in a consistent manner and reliably performed as indicated.There are a number of oral care interventions that all patients should receive and a fewadditional ones that are specific to ventilated patients.

Recommended Oral Care Interventions for ALL Hospitalized Patients37

Written Protocol and Training (See Appendix B) Intervention:Written oral care protocol and training should be in place. Rationale: Policy is designed to provide a standard of care which should be

reinforced in training and should allow for consistent care of all patients.

Initial Assessment (See Appendix C) Intervention:Conduct an initial admission assessment of the patients oral

health and self-care deficits. Rationale:Assessment allows for initial identification of oral hygiene concerns.

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Dental Plaque Removal Intervention: Use a small, soft toothbrush to brush teeth, tongue and gums at

least twice daily to remove dental plaque. Foam swabs or gauze should not beused, as they are not effective tools for this task.

Rationale:Dental plaque, identified as a source of pathogenic bacteria

associated with respiratory infection, requires mechanical debridement fromtooth, tongue and gingival surfaces.

Toothpaste Intervention:Use toothpaste containing additives which assist in the breakdown

of mucus and biofilm in the mouth. Rationale:Additives such as sodium bicarbonate have been shown to assist in

removing debris accumulations on oral tissues and teeth.

Antiseptic Mouth Rinse Intervention:Use an alcohol-free, antiseptic rinse to prevent bacterial

colonization of the oropharyngeal tract. Rationale:Mouthwashes with alcohol cause excessive drying of oral tissues.Hydrogen peroxide and CHG-based rinses have been shown to assist incleaning debris buildup and provide antibacterial properties.

Moisturizer Intervention:Use a water-soluble moisturizer to assist in the maintenance of

healthy lips and gums at least once every two hours. Rationale:Dryness and cracking of oral tissues and lips provides regions for

bacterial proliferation. A water-soluble moisturizer allows tissue absorption andadded hydration.

Intervention:Avoid using lemon-glycerin swabs for oral care to moisten oralmucosa.

Rationale:Lemon-glycerin compounds are acidic and cause drying of oraltissues.

Recommended Oral Care Interventions for Ventilated Patients37 (See Appendix D)

Assessment of Oral Cavity (See Appendix E) Intervention:Conduct an initial admission as well as daily assessment of the

lips, oral tissue, tongue, teeth, and saliva of each patient on a mechanicalventilator.

Rationale:Assessment allows for initial identification of oral hygiene problemsand for continued observation of oral health.

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Maintain Saliva Intervention:Unit specific protocols should be implemented that assist patients

at risk of VAP in maintaining saliva production, oral tissue health and minimizingdevelopment of mucositis.

Rationale:Saliva provides both mechanical and immunological effects which act

to remove pathogens colonizing the oropharynx.

Elevate Head Intervention:Keep head of bed elevated at least 30[unless medically

contraindicated], and position patient so that oral secretions pool into the buccalpocket; especially important during such activities as feeding and brushing teeth.

Rationale:Elevation aids in preventing reflux and aspiration of gastric contents;oral secretions may drain into the subglottic area where they can become rapidlycolonized with pathogenic bacteria.

Subglottic Suctioning

Intervention:Patients oral and subglottic secretions should be suctionedcontinuously or intermittently/routinely with the frequency dependent uponsecretion production.

Rationale:Minimize aspiration of contaminated secretions into lung.

Conclusion

Inadequate or improper oral care puts patients at risk for hospital-acquired pneumonia.Pneumonia is a prevalent, morbid infectious disease that accounts for approximately15% of all hospital-acquired infections. Due to the severity of this disease, it isimperative that medical personnel become knowledgable of theclinical classifications ofpneumonia and risk factors associated with the development of hospital-acquiredpneumonia. Ventilated patients are especially at risk for pneumonia as their normalhost defenses and secretion clearance mechanisms are disrupted by assisted-breathingdevices. Establishing and following effective pneumonia prevention strategies isessential in reducing the occurrence of pneumonia. One prevention strategy that isoften overlooked is a comprehensive oral care protocol that requires a thoroughunderstanding of the oral environments role in the development of pneumonia. Byincorporating a comprehensive oral care protocol into the facilitys current VAPreduction bundle of best practices, lives can be saved!

COMPREHENSIVE ORAL CARE REALLY DOESMAKE A DIFFERENCE!Oral Care Is Critical Care for All Patients

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Centers for Disease Contro l & Prevention (CDC)Healthcare Infection Control Practices Advisory Committee

(HICPAC)16

Prevention of Health-CareAssociated Bacterial PneumoniaIV. Modifying Host Risk for Infection

B. Precautions for prevention o f aspiration3. Prevention or modulation of oropharyngeal colonization

a. Oropharyngeal cleaning and decontamination with anantiseptic agent: develop and implement a comprehensiveoral-hygiene program (that might include the use of anantiseptic agent) for patients in acute-care settings orresidents in long-termcare facilities who are at high risk forhealth-careassociated pneumonia (II) (156,157).

b. Chlorhexidine oral rinse1)No recommendation can be made for the routine use of

an oral chlorhexidine rinse for the prevention of health-careassociated pneumonia in all postoperative orcritically ill patients and/or other patients at high risk forpneumonia (Unresolved issue) (II) (158).

2)Use an oral chlorhexidine gluconate (0.12%) rinse duringthe perioperative period on adult patients who undergocardiac survery (II) (158).

c. Oral decontamination with topical antimicrobial agents.1)No recommendation can be made for the routine use of

topical antimicrobial agents for oral decontamination toprevent VAP (Unresolved issue) (159).

Association of Cri tical-Care Nurses (AACN)Assess oral cavity and lips every 8 hours, and perform oral careevery 2 to 4 hours and as needed.

1 With oral care, assess for buildup

of plaque on teeth or potential infection related to oral abscesses.

Perform oral hygiene, using pediatric or adult (soft) toothbrush, atleast twice a day. Gently brush patients teeth to clean and removeplaque from teeth.1

In addition to brushing twice daily, use oral swabs with a 1.5%hydrogen peroxide solution to clean mouth every 2 to 4 hours.1

With each cleansing, apply a mouth moisturizer to the oral mucosaand lips to keep tissue moist.

1

Suction oral cavity/pharynx frequently.2

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References

1. Richards MJ, Edwards JR, Culver DH, Gaynes RP. Nosocomial infections in medical intensive care units in the UnitedStates. National Nosocomial Infections Surveillance System. Crit Care Med 1999 May;27(5):887-92.

2. Richards MJ, Edwards JR, Culver DH, Gaynes RP. Nosocomial infections in coronary care units in the United States.National Nosocomial Infections Surveillance System. Am J Cardiol 1998 Sep;82(6):789-93.

3. Kollef MH. Diagnosis of ventilator-associated pneumonia. N Engl J Med 2006 Dec;355(25):2691-3.

4. Van Hooser DT. Ventilator-Associated Pneumonia (VAP): Best Practice Strategies for Caregivers. 2002. Kimberly-ClarkHealth Care.

5. Collard H, Saint S. Prevention of Ventilator0Assocuiated Pneumonia. Agency for Healthcare Research Quality EvidenceReport/Technology Assessment No.43, Making Healthcare Safer: A Critical Analysis of Patient Safety Practices. AHRQPublication No. 01-E058, full report, 01-E057, summary. Agency for Healthcare Research Quality; 2001. p 185-203.

6. Zack J. 2004. W.H.A.P. V.A.P.! Ventilator-Associated Pneumonia.

7. Girard R, Perraud M, Pruss A, Savey A, Tikhomirov E, Thuriaux M, Vanhems P. Prevention of Hospital-Acquired Infections:A Practical Guide. Ducel, G, Fabry, J, and Nicolle, L. Online [2nd]. 2002. World Health Orgainzation.

8. Hixson S, Sole M, King T. Nursing Strategies to Prevent Ventilator-Associated Pneumonia. AACN 1998 Feb;9(1):76-90.

9. Unertl K. Ventilator-Associated Pneumonia. Online . 9-22-2000.

10. Roark J. Fighting Nosocomial Pneumonia. Infection Control Today 7[5], 14-18. 2003.

11. Rello J, Ollendorf D, Oster G, Vera-Llonch M, Bellm L, Redman R, Kollef M. Epidemiology and Outcomes of Ventilator-Associate Pneumonia in a Large US Database. Chest 2002 Dec;122(6):2115-21.

12. Rello J, Paiva JA, Baraibar J, Barcenilla F, Bodi M, Castander D, Correa H, Diaz E, Garnacho J, Llorio M, Rios M, RodriguezA, Sole-Violan J. International Conference for the Development of Consensus on the Diagnosis and Treatment of Ventilator-associated Pneumonia. Chest 2001 Sep;120(3):955-70.

13. Hubmayr RD, Burchardi H, Elliot M, Fessler H, Georgopoulos D, Jubran A, Limper A, Pesenti A, Rubenfeld G, Stewart T,Villar J. Statement of the 4th International Consensus Conference in Critical Care on ICU-Acquired Pneumonia--Chicago,

Illinois, May 2002. Intensive Care Med 2002 Nov;28(11):1521-36.

14. Kollef MH. The prevention of ventilator-associated pneumonia. N Engl J Med 1999 Feb;340(8):627-34.

15. WHO. Burden of Disease. 1999.

16. Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R. Guidelines for preventing health-care--associated pneumonia,2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep2004 Mar;53(RR-3):1-36.

17. Mori H, Hirasawa H, Oda S, Shiga H, Matsuda K, Nakamura M. Oral care reduces incidence of ventilator-associatedpneumonia in ICU populations. Intensive Care Med 2006 Feb;32(2):230-6.

18. [Anonymous]. Hospital-acquired pneumonia in adults: diagnosis, assessment of severity, initial antimicrobial therapy, andpreventive strategies. A consensus statement, American Thoracic Society, November 1995. Am J Respir Crit Care Med

1995 Nov;153(5):1711-25.

19. American Thoracic Society, Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 171[4], 388-416. 2-15-2005.

20. Safdar N, Crnich CJ, Maki DG. The pathogenesis of ventilator-associated pneumonia: its relevance to developing effectivestrategies for prevention. Respir Care 2005 Jun;50(6):725-39.

21. van Nieuwenhoven CA, Buskens E, Bergmans DC, van Tiel FH, Ramsay G, Bonten MJ. Oral decontamination is cost-savingin the prevention of ventilator-associated pneumonia in intensive care units. Crit Care Med 2004 Jan;32(1):126-30.

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22. DeFrances CJ, Podgornik MN. 2004 National Hospital Discharge Survey. Advance data from vital and health statistics; no371.Hyattsville, MD: National Center for Health Statistics. 5-4-2006.Ref Type: Generic

23. Kikawada M, Iwamoto T, Takasaki M. Aspiration and infection in the elderly : epidemiology, diagnosis and management.Drugs Aging 2005;22(2):115-30.

24. Bartlett JG, Breiman RF, Mandell LA, File TM. Community-acquired pneumonia in adults: guidelines for management. TheInfectious Diseases Society of America. Clin Infect Dis 1998 Apr;26(4):811-38.

25. [Anonymous]. Airway Management. In: Hess D, Kacmarek R, editors. Essentials of Mechanical Ventilation. 2nd ed. NewYork: McGraw-Hill; 2002. p 295-306.

26. Gibbons RJ. Bacterial adhesion to oral tissues: a model for infectious diseases. J Dent Res 68[5], 750-760. 1989.

27. Munro CL, Grap MJ. Oral health and care in the intensive care unit: state of the science. Am J Crit Care 2004 Jan;13(1):25-33.

28. Berry AM, Davidson PM. Beyond comfort: Oral hygiene as a critical nursing activity in the intensive care unit. Intensive CritCare Nurs 2006 Jun.

29. Bagg J ea. The oral microflora and dental plaque. Essentials of microbiology for dental students. Oxford: Oxford UniversityPress; 1999. p 229-310.

30. Adachi M, Ishihara K, Abe S, Okuda K, Ishikawa T. Effect of professional oral health care on the elderly living in nursinghomes. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002 Aug;94(2):191-5.

31. Scannapieco FA, Wang B, Shiau HJ. Oral bacteria and respiratory infection: effects on respiratory pathogen adhesion andepithelial cell proinflammatory cytokine production. Ann Periodontol 2001 Dec;6(1):78-86.

32. Dennesen P, van d, V, Vlasveld M, Lokker L, Ramsay G, Kessels A, van den KP, van Nieuw AA, Veerman E. Inadequatesalivary flow and poor oral mucosal status in intubated intensive care unit patients. Crit Care Med 2003 Mar;31(3):781-6.

33. APIC. Preventing Ventilator Associated Pneumonia. Infection Control Week 2004 Brochure . 8-1-2007.

34. IHI. Protecting 5 Million Lives From Harm Campaign. Getting Started Kit: Preventing Ventilator-Associated Pneumonia How-to Guide. Online . 8-1-2007.

35. Stogsdill V, Hobgood L, O'Bryan S, O'Bryan W, Thompson L, Sisley M. Reducing Ventilator-Associated Pneumonia.http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/ImprovementStories/ReducingVentilatorAssociatedPneumoniaOwensboro.htm. 8-1-2007.

36. Scott J, Vollman K. Procedure 4. Endotracheal Tube and Oral Care. In: Wiegand D, Carlson K, editors. AACN ProcedureManual for Critical Care. 5th ed. St. Louis: Elsevier Saunders; 2005. p 28-33.

37. Garcia R. A review of the possible role of oral and dental colonization on the occurrence of health care-associatedpneumonia: underappreciated risk and a call for interventions. Am J Infect Control 2005 Nov;33(9):527-41.

38. Scannapieco FA, Mylotte JM. Relationships between periodontal disease and bacterial pneumonia. J Periodontol 1996Oct;67(10 Suppl):1114-22.

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Appendix A: Oral Care Glossary

antibiotic resistant Refers to the ability of bacteria and other microorganisms towithstand the effects of an antibiotic (survive and reproduce) to

which they were once sensitive (and were once stalled or killedoutright). Also called drug resistance.

antibiotic sensitive The susceptibility of microorganisms such as bacteria to antibiotictherapy. If the growth of the organism is inhibited by the action ofthe antibiotic, it is sensitive to that drug.

aspiration Aspiration means to draw in or out using a sucking motion, oftenpurposely. This medical term has two meanings, depending onhow it is used:

1. the drawing of a foreign substance, (usually food, liquids,gastric contents, or secretions from the mouth), into therespiratory tract (airway, lungs) during inhalation. This may leadto an inflammatory reaction, a lung infection (pneumonia), or acollection of pus in the lungs.38

2. a medical procedure that removes harmful or misplacedsubstances, such as air, body fluids, bone fragments or gas, froman area of the body by suction, using an aspirator (i.e., yankauer).

buccal (bk'l) Inside the cheek or mouth or the gum beside the cheek.

community-acquired pneumonia23 Pneumonia that develops in a patient who resides in thecommunity and has not been in a healthcare environment for atleast 90 days or has not resided in a long-term-care facility formore than 14 days before the onset of symptoms.

Clinical Pulmonary InfectionScore (CPIS)

A common survey of physical parameters which may indicateincreasing risk of VAP.

healthcare-associated pneumonia(HCAP)

Pneumonia that develops in a patient within 90 days of residing inany healthcare environment including but not limited to nursinghomes, ambulatory surgical centers, hospitals, long term carefacilities.

hospital-associated pneumonia(HAP)

Pneumonia that develops in a patient 48 hours after admission,that was not present upon admission. This type of pneumoniatends to be more serious because the patient's immune system isoften already impaired. In addition, there is a greater possibility ofinfection with bacteria that are resistant to antibiotics.

immunosuppression The immune system's inhibited ability to respond to antigenicstimuli; caused by disease or the use of certain drugs.

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mucociliary escalator(my-k-sil-- er- es-k- l-tr)

The mechanism by which mucus is removed; mucus istransported upwards from the trachea and downwards by ciliafrom the nose to the back of the throat.

mucositis (my-k- st-s) Inflammation of a mucous membrane; orally, results in increasedoropharyngeal colonization with respiratory pathogens; commoncauses include: age, medication, illness.

mucus/mucous A slippery secretion usually rich in mucins and is produced by

mucous membranes which it moistens and protects.

nosocomial pneumonia Also known as hospital-associated pneumonia (HAP); any case ofpneumonia that starts at least 48 hours after admission into anacute healthcare facility.

oropharyngeal (r--f-rinj-l) Of or relating to the part of the pharynx that is below the softpalate, above the epiglottis and at the back of the mouth.

papillae (p-pil ) Small elevated protuberances on the tongue.

phagocytosis (fag--s-t-ss) An important body defense mechanism against infection and

foreign particulates; the engulfing and usually the destruction ofparticulate matter by phagocytes and leukocytes such aspolymorphonuclear leukocytes (PMLs).

pneumonia An acute inflammation of the lungs caused by an infection fromorganisms such as Streptococcus pneumoniae, other bacteria,viruses, rickettsiae, and fungi. The alveoli and bronchioles of thelungs become plugged with a fibrous exudate.

ventilator-associated pneumonia(VAP)

A subset of HAP; a nosocomial pneumonia that develops inpatients after they have been on mechanical ventilator support for48 hours.

xerostomia (zir--st-m-) Dryness of the mouth caused by abnormal reduction in theamount of salivary secretion due to fever, medication, diarrhea,disease, or medical therapy.

yankauer An oral suction device designed to allow effective suction withoutaspiration of surrounding tissue.

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ORAL CARE IS CRITICAL CAREThe Role of Oral Care in the Prevention of Hospital-Acquired Pneumon ia in Hospitalized

Patients


Post Test

Name: _________________________________________

Match the following acronyms with their appropriate definitions.

A. CAP B. HCAP C. HAP D. VAP

1. _____ Pneumonia in a patient who resides in the community and has not been in a healthcareenvironment for at least 90 days or has not resided in a long-term-care facility for morethan 14 days before the onset of symptoms

2. _____ Pneumonia in a patient who has been on ventilatory support for at least 48 hours

3. _____ Pneumonia in a patient within 90 days after discharge from an acute care hospital,nursing home or extended care facility, or who receive dialysis services or home care andpresent with pneumonia on admission to an acute care facility

4. _____ Pneumonia in a patient that develops at least 48 hours after admission and the infectionwas not present or incubating on admission

Place the following stages of the Path to VAP in order of development (1-4).

5. _____ Lungs contaminated with microorganisms

6. _____ Contamination/colonization with bacteria above the cuff

7. _____ Impaired natural protection/clearance system

8. _____ Aspiration of microorganisms into the lungs directly through the ET tube or around the cuff

Multiple Choice

9. _____ According to the list in the study guide, which of the following is NOT a risk factor for thedevelopment of pneumonia in hospitalized patients?

A. Supine positionB. Extremes of ageC. Repeated endotrachedal intubationD. Admission to the hospital

10. _____ Which of the following groups recommend the use of a comprehensive oral care protocol?A. CDC B. APIC C. AACN D. All of the above E. None of the above

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EvaluationOral Care Is Critical Care:

The Role of Oral Care in the Prevention of Hospital-Acquired Pneumonia

Please print clearly and fill in all data to ensure accurate record-keeping.

Name: License State and #:*

Title: SSN:* (if license # not available)

Facility Name:

Home address:

City: State: Zip:

Home Phone: Work Phone:(*) Either your Social Security Number or License number is required to obtain CE Credit.Please check appropriate box: RN/LPN Surg Tech Resp Therapist CS Sup/Mgr Other

Date: ___________________________ Faci li tator: _______________________________The evaluation process is important to determine the extent to which this program has met your learningneeds and to measure its overall effectiveness. Circle the number that best reflects the extent of youragreement with each statement.

Rating Scale: 1=Poor to 5=ExcellentObjectives: Poor ExcellentIndicate to what degree the objectives for thi s program were met.1. Understand the clinical classifications of pneumonia. 1 2 3 4 52. Discuss the risk factors of Hospital-Acquired Pneumonia (HAP) andVentilator-Associated Pneumonia (VAP) 1 2 3 4

5

3 Describe the path to Ventilator-Associated Pneumonia (VAP) 1 2 3 4 54. Explain the role of the oral environment in the development of Hospital-

Acquired Pneumonia (HAP) and Ventilator-Associated Pneumonia (VAP) 1 2 3 4

55. Examine recommended oral care interventions and the evidence-basedrationales for these patient care practices 1 2 3 4

5

Overall Evaluation Poor Excellent6. Content 1 2 3 4 57. Expertise of author 1 2 3 4 58. Audiovisual materials 1 2 3 4 59. Handout materials 1 2 3 4 510. Overall quality of the program 1 2 3 4 5

Program Integrit y: Indicate your agreement with the following statement DisagreeAgree11. The content in this course was presented without bias of any commercial

product or drug. 1 2 3 4

512. How long did it take you to complete this program? ________________________13. What other topics would be of benefit to you? ________________________________________14. Additional comments.

Iowa Nurses Only: Please complete and leave evaluation form with conference coordinator at the conclusion of the conference in exchange for aCertificate of Completion, or you may submit the evaluation form to the Iowa Board of Nursing.Florida registered nurses must provide your Florida RN license number.

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4 -Oral Care Study Guide

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